Comparing U.S., Canadian health care systems

About Trudy Lieberman

Trudy Lieberman, a former president of AHCJ, is a contributing editor to the Columbia Journalism Review, where she blogs about health care and income security issues. She is a fellow at the Center for Advancing Health where she blogs about paying for health care. At Consumer Reports, she specialized in health care and health care financing. She has won more than 25 awards and five major fellowships.

Lieberman recently returned from a monthlong visit to Canada as a Fulbright Senior Specialist, where she lectured on the American health care system and learned much about how Canadians get their medical care. She interviewed hospital executives, physicians, academic experts, former health ministers, reporters covering health care, and ordinary citizens. Lieberman also toured hospitals and long-term care facilities. This is the first of four posts reporting on that visit.

One thing Americans and Canadians can agree on is that we don’t want each other’s health care systems. In truth, most Americans don’t know how Canada’s system works and Canadians don’t know much about the U.S. system.

What Americans know has come mainly from the negative talking points of politicians and others who have argued for years against national health insurance. Two decades ago TheNew York Times reported that Canadian women had to wait for Pap smears, a point vigorously refuted by the Canadian ambassador who shot back in a letter to the Times editor: “You, and Americans generally, are free to decide whatever health care system to choose, avoid or adapt, but the choice is not assisted by opinions unrelated to fact.”

Yes, there are waiting lists for some services – as I will explain in another post – but, no, Canadians are not coming across the border in droves to get American care.

There’s misinformation among Canadians, too. Wherever I went, Canadians told me they thought, mostly based on what they said they heard on CNN and Fox, that Obamacare meant America was getting universal health coverage like their country has.

When I explained the law was simply another patch on a patchwork quilt of coverage, and the Congressional Budget Office had estimated last year there would still be some 30 million people without insurance, the reaction was “the news media didn’t tell us that.” A former deputy health minister in New Brunswick said to me, “After all that, you will still have 30 million people without coverage!”

Separating fact from opinion as the Canadian ambassador long ago urged was something I tried to do as I made my way across the country. In some ways the Canadian system is very different from U.S. health care. In other ways it’s very much the same and faces similar challenges in the years ahead.

What we don’t share

Although the Affordable Care Act calls for more people to have health insurance by offeringsubsidies and mandating all Americans have it or face penalties, the concept of universality is still a far distant goal. The Canada Health Act, on the other hand, calls for universality – all residents must be covered by the public insurance plan run by their province on uniform terms and conditions. They have coverage wherever they are treated in the country, and there’s none of this stuff about limiting the doctors and hospitals that patients can use as a condition of getting full benefits. In Canada there are no financial barriers to care at the point of service as there are and will continue to be in the U.S.

Canadians don’t pay coinsurance of 30 percent or 50 percent if they have an outpatient procedure or go to an urgent care clinic, charges that are becoming increasingly common here. They don’t worry about paying a gigantic bill if they happen to use an out-of-network doctor or hospital. The publicly funded system north of the border bases patients’ access to medical services on need, not on the ability to pay. To use the word “ration,” Canadians ration by need; Americans ration by price and will continue to do so as the ACA is implemented.

Because it’s publicly funded, Canadian health care is more equitable. There’s no such thing as buying a platinum plan and getting first-rate coverage or a cheapo bronze policy and paying 60 percent of the bill yourself. The tiered policies available in the state exchanges further bake inequality into the U.S. system. People have wildly varying benefits depending on where they live, how old they are, where they work, and how much they can afford to spend on health insurance.

That’s not the case in Canada, except when it comes to prescription drug coverage. Drug benefits are quite unequal in Canada, and the lack of them is a pretty big hole for about 10 percent of the population. There is no universal drug benefit, although two provinces have mandatory drug insurance – you can get it from an employer or buy it from a public plan. About 40 percent of the population gets coverage from their employers. If you can’t afford the premium, there are subsidies. In that sense, Canadian drug coverage in those provinces resembles Obamacare. Still, having drug benefits does not necessarily mean adequate coverage, says Globe and Mail health columnist André Picard. “The big difference from the rest of Canada’s system is there is very little first-dollar coverage of prescription drugs.”

On this trip I heard much more about the social determinants of health than I hear in the U.S. Almost everyone I interviewed mentioned the dismal health stats for aboriginal populations and the need to improve access and quality of care. I tried to remember the last time I heard anyone discuss the medical problems of Native Americans or quality of care provided by the Indian Health Service.

I asked Michael Decter, a health policy expert and a former deputy health minister in Ontario, what was his wish list for Canadian health care. Topping his list was not more money for the health system; it was more for education aimed at improving the lives of aboriginal peoples. Better education correlates with better health. The second was drug coverage. Canada’s infamous waiting times were not high on his list of priorities. In fact, he didn’t even mention them as a problem.

Coming up

In Lieberman’s next post, she’ll share what the Canadian and U.S. health care systems do have in common with a look at the cost and quality of care, the challenges of meeting the needs of vulnerable populations, caring for aging populations and more.

6 thoughts on “Comparing U.S., Canadian health care systems”

Why are we still talking about rationing by price or by need? This is just to get around the ideologue’s palaver. Now that we have acknowledged that resources are finite, can we move forward and ask what a health system is SUPPOSED to deliver.

1. Prevent bankruptcy from catastrophic illness.
2. Provide EVIDENCE-BASED services to all irrespective of income. (rationing by evidence, interesting idea?)
3. Improve the health of the workforce at reasonable cost so as to be more economically competitive. (Some people don’t like this because it sounds like its all about the money, but economic competitiveness is a path to vocational meaning, an important aspect of quality of life.)
4. Cost effectively support those who cannot work for a variety of reasons; the disabled, the disadvantaged, the mentally ill, the abused, the disempowered, the victimized… and yes, the moochers, since putting up too many obstacles to the group you are targeting means you won’t reach them, so there will always be some free-riding, whose impact you can work to mitigate, but cannot eliminate.
5. Increase the cost-effectiveness of accessing technological care, even for those who can afford it, because international employers are less likely to come to a country where insurance premiums will bankrupt them.

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